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Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists

Posted on: Friday, 29 April 2005, 03:00 CDT

Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists Edited by Kia J. Bentley, PhD The Haworth Social Work Practice Press, ISBN 0-7890-2401-2, 146 pages, $19.95 in softbound.

This book presents a collection of seven articles that critically analyze the problems of contemporary psychiatric medication from the perspective of non-physician mental health providers such as social workers, counselors, and psychologists. These critical views pretend to have "an independent understanding of medications" and, by analogy, with a movement of the sixties, could be named the anti- psychiatry of our times. Paradoxically, old and new psychopharmacological agents (e.g., antipsychotics/antimanic, antidepressants, anxiolitics, and moodstabilizers) introduced into clinic practice for effective treatment of serious mental disorders and that have allowed transferring treatment from the state psychiatric hospitals to the community, are today the object of intense criticism. Surprisingly, many of the negative attitudes held by non-medical mental health professionals towards psychotropic medications do not differ from the skeptical notions of the lay public.

In his programmatic article on the history of psychiatric medication (Chapter 1), David Cohen speculates that "...little evidence exists that any drug used in psychopharmacology will actually surpass an active placebo in reducing target symptoms" (p. 15). In fact, there is no lack of evidence for significantly more (or less) efficacy of an experimental drug over placebo in any adequately controlled clinical trial. The true problem is the discrepancy between the efficacy that an experimental drug demonstrates in clinical trials and its effectiveness in daily clinical practice. One possible explanation for this discrepancy is that the service context of clinical trials is essentially different from routine psychiatric care. The main difference is the selection of patients characterized by predominance of specific types of symptoms, and the application of multiple exclusion criteria in usual clinical trials. In addition, only the experimental compound in a restrictively defined dosing regimen is administered in a trial, whereas polypharmacy and a broad dosage range are prevalent in everyday practice. As a result, clinical trials recruit patients who tend to be in a minority, while findings and conclusions have been generalized to entire populations of patients with similar diagnoses.

In Chapter 2, Sarah Bradley, describing the psychology of the so- called psychopharmacology triangle-the client, the clinician, and the medicationcriticizes the existing system of care based on a medical model and psychiatry focusing on biological rather than on the bio-psychosocial nature of mental disorders. She justly indicates that this system relies on the utilization of pharmacological interventions and, correspondingly underevaluates "relationship factors,""motivation to change,""placebo-effect," and the client's beliefs, values, hopes, expectations, all of which can play a meaningful part in positive outcome. She assumes that competitive relationships among the different sides of the triangle must be replaced by collaborative treatment structure that "provides a consistent and predictable holding environment for all three partners" (p. 48).

Jerry Floersch (Chapter 3) outlines a conceptual framework for mapping the sociocultural context of medication management in children and adolescents. He underscores that for an adolescent, a peer may be more important than a parent, psychiatrist, or care manager in the rationalization of the need for treatment and the interpretation of its effects. Developing further the topic of subjective experience of antipsychotic treatment, he and his co- authors, Jeffrey Longhofer and Janis Jenkins (Chapter 4) introduce the concept of drug "aporia" that is defined as an "interpretative gap between a client's desired and perceived effects of psychotropic drug treatment." Unfortunately, since both desired and perceived effects are subjective, this notion is vague and does not help a practitioner to answer the question: Why does this distance vary for the same medication in different patients? In other words, is this gap dependent on the social situation of the individual rather than on a specific biological responsiveness of his/her organism? Chapter 5 by Joseph Walsh, Rosemary Farmer, Melissa Taylor, and Kia Bentley is based on an empirical study reporting the results of the national survey of practicing social workers, and presents the ethical dilemmas they face when working with clients on psychiatric medication. The major issues recognized are: a) clients' right to refuse medication; b) self-determination versus paternalism; and c) the social worker's relationship with the prescribing physician. The latter are among the most worrisome because this relationship will affect how well the patient is treated by the prescribing physician. Consequently, social workers should build trusting partnerships not only with clients and families but also with physicians. Clear guidelines on how to achieve this are needed.

In the sixth chapter, Jill Littrell discusses the medico-legal and ethical problems that social workers face when seeking informed consent for psychiatric medication from their clients. Should social workers offer information to clients about medications that differ from the one the physician has given a patient? Should a social worker recommend medication as the best solution for individuals with a mental health diagnosis and advocate for medication compliance? Unfortunately, the author, a psychologist dealing with people with mental disorders in the social work field, raises but does not answer these essential ethical issues.

Most interesting is the final chapter by Sophia Dziegielewski. It surveys nonconventional methods and alternative approaches that have supplemented or replaced traditional therapeutic practices. Among them we find homeopathy, naturopathy, traditional Chinese medicine and Ayurveda, osteopathy, chiropractic, aromatherapy, environmental medicine as well as hypnotherapy, biofeedback, relaxation techniques, massage, postural/ energy therapies, dietary (nutritional) supplements, etc. Interestingly, the knowledge of alternative medicine is now one of the criteria to assess the qualification of primary care physicians in the most European countries. Unfortunately, the chapter contains no mention of the rapidly developing and promising area of the treatment of severe mental disorders by the nutritional supplementation of essential fatty acids, concentrations of which were found to be abnormally low in patients with schizophrenia and major depressive disorders.

In conclusion, despite the underlying high critical tone and, at times, superficial judgments about the current status of psychiatric treatment of mental health disorders, this easy-to-read book could be useful for neophytes in mental health care and possibly for medical students because of its emphasis on the negative sides of modern clinical psychopharmacology as opposed to the trends of the agents of pharmacological companies and prescribing physicians who are prone to report more information on its benefits. Nevertheless, those who criticize psychiatric treatment from the social worker and psychologist's perspectives should not forget that only progress in this field (not in psychoanalysis or other kinds of psychotherapy) is what integrates psychiatry into the remaining fields of medicine.

REVIEWED BY

ALEXANDER M. PONIZOVSKY MD, PHD

Copyright Psychosocial Rehabilitation Journal Spring 2005

Source: Psychiatric Rehabilitation Journal

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